Every finding on record at Howard County Community Hospice

Based on hospice staff interview, clinical record review and hospice policy review, the hospice failed to have all members of the Interdisciplinary group complete the comprehensive assessment no later than 5 calendar days after the election of hospice care for 6 of 14 sampled patients (Patient #4, #6, #7, #8, #10 and #13).  Failure to have all disciplines complete the comprehensive assessment within 5 calendar days of the election of hospice care put patients at risk for inconsistent care that may not meet the needs of the patient. --- 5.Patient #7 had a hospice admission date of 5/27/25 and received services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 5/27/25 to 8/24/25, failed to include documentation the social worker was involved in completing the initial comprehensive assessment and development of the plan of care.    b. The clinical record lacked a social work assessment or documentation of why a social work assessment was not completed.    The social worker failed to complete an assessment no later than 5 calendar days after the election of hospice services or document why the assessments were not completed within the required time frame.    6. Patient #10 had a hospice admission date of 5/12/25 and received services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 5/12/25 to 8/9/25, included physician orders for Social work services 1-2 times per month.    b. IDG meeting note, dated 5/14/25, included documentation Social work services were ordered on initial plan of care and for the next two weeks.    c. Social work initial visit note, dated 5/23/25, completed by Staff H, Social Worker, 11 days after admission and 6 days late according to the required time frame.    The social worker failed to completed an assessment no later than 5 calendar days after the election of hospice services or document why the assessment was not completed within the required time frame.    The above findings were reviewed with the Administrator and Clinical Manager.   Findings include:  Review of the hospice policy, titled Clinical Record Documentation and Retention, dated 4/30/25, identified time frames for completion and transfer of documentation for admission assessment for registered nurses – initial assessment documentation completed by the 5th calendar day of the start of care, comprehensive assessment documentation completed by the 5th calendar day of the start of care.  For social workers – by the 5th day of the start of care.  Any other member of the Interdisciplinary group may participate in the initial or comprehensive assessment.  Review of the hospice policy, titled Comprehensive Assessment Policy – Hospice, dated 4/30/25, identified the comprehensive assessment will be completed upon admission and will be documented within 5 days of admission.  During an interview on 6/17/25 at 10:36 AM, Staff H, Social Worker, reported they are generally involved in all initial assessments, typically they get out there within 5 days to get assessment done.  There may be a time when they don’t go within the 5 days if there was a scheduling conflict or they weren’t in the office.  1.Patient #4 had a hospice admission date of 2/14/25 and received services while residing in a private home.  Clinical record review revealed the following:  a. Plan of Care, dated 2/14/25 to 5/14/25, included physician orders for Social work services 1-2 times per month.  b. Interdisciplinary Group (IDG) meeting note, dated 2/19/25, included documentation Social work services were ordered on initial plan of care and for the next two weeks.  c. Communication note, dated 2/19/25, included documentation Social worker had not made a formal visit yet, spoke with patient extensively at time of consents and will start visits soon.  d. Communication note, dated 3/5/25, included documentation social worker did not have an official visit after admission and will meet with patient this month.  e. Communication note, dated 3/19/25, included documentation social worker has not seen patient since admit and patient is not sure they want social work support.  Social work services will be discontinued per nurse recommendation.  The social worker failed to complete an assessment no later than 5 calendar days after the election of hospice services or document why the assessment was not completed within the required time frame.  2. Patient #6 had a hospice admission date of 3/31/25 and received services while residing in a nursing home.  Clinical record review revealed the following:  a. Plan of Care, dated 3/31/25 to 5/29/25, included physician orders for Chaplain services 1-2 times a month.  b. IDG meeting note, dated 4/2/25, included documentation Chaplain services were ordered on initial plan of care and for the next two weeks.  c. Chaplain visit note, dated 4/13/25, included documentation a chaplain assessment was completed, 13 days after the admission date and 8 days after the 5 day window after election of hospice services.  The Chaplain failed to complete an assessment no later than 5 calendar days after the election of hospice services or document why the assessment was not completed within the required time frame.  3. Patient #8 had a hospice admission date of 6/2/25 and received services while residing in an assisted living facility.  Clinical record review revealed the following:  a. Plan of Care, dated 6/2/25 to 8/30/25, included physician orders for Chaplain services 1-2 times a month.  b. IDG meeting note, dated 6/11/25, included documentation Chaplain services were ordered on initial plan of care and for the next two weeks.  c. Chaplain visit note, dated 6/9/25, included documentation a chaplain assessment was completed, 7 days after the admission date and 2 days after the 5 day window after election of hospice services.  d. Clinical record lacked Social work assessment or documentation of why social work assessment was not completed.  The Chaplain and social worker failed to complete assessments no later than 5 calendar days after the election of hospice services or document why the assessments were not completed within the required time frame.  4. Patient #13 had a hospice admission date of 11/14/24, a death date of 11/29/24 and received services while residing in a private home.  Clinical record review revealed the following:  a. Plan of Care, dated 11/14/24 to 2/11/25, included physician orders for Social work services 1-2 times per month.  b. IDG meeting note, dated 11/27/24, included documentation Social work services were ordered on initial plan of care and for the next two weeks.  c. Communication note, dated 11/27/24, included documentation social worker met with patient and caregiver prior to admission and no visits have taken place since admission.  The social worker failed to complete assessments no later than 5 calendar days after the election of hospice services or document why the assessments were not completed within the required time frame.

Based on clinical record review and hospice policy review, the hospice failed to ensure the provision of care in accordance with the patient's plan of care for 6 of 14 sampled patients (Patients #1, #2, #5, #8, #10 and #14).    Failure to follow the patient's Plan of Care as directed by the Interdisciplinary Group (IDG) put the patient at risk for inconsistent care that may not meet the needs of the patient. --- 3.Patient #2 had a hospice admission date of 2/24/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 4/25/25 to 6/23/25, identified the patient had a diagnosis of Metachromatic leukodystrophy and included physician orders for skilled nursing services 1-2 times a week.   b.  Staff C, Skilled nurse, provided services on 4/28/25, 5/1/25, 5/1/25 (second visit of day) and 5/2/25; exceeding the ordered visit frequency for the week of 4/27/25 by two visits.    c. The IDG meeting notes, dated 4/30/25 and 5/14/25, lacked documentation of variations to skilled nursing services ordered 1-2 times a week.     The hospice failed to follow all orders as directed by the IDG.     4. Patient #5 had a hospice admission date of 4/22/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 4/22/25 to 7/20/25, identified the patient had a diagnosis of Senile degeneration of the brain and included physician orders for hospice aide services 2-3 times a week.   b.  Hospice aide provided services on 4/29/25, 4/29/25 (second visit of day), 4/30/25 and 5/1/25; exceeding the ordered visit frequency for the week of 4/27/25 by one visit.    c. The IDG meeting notes, dated 4/30/25 and 5/14/25, lacked documentation of variations to aide services ordered 2-3 times a week.    The hospice failed to follow all orders as directed by the IDG.    5. Patient #10 had a hospice admission date of 5/12/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 5/12/25 to 8/9/25, identified the patient had a diagnosis of Alzheimer's disease and included physician orders for skilled nursing services 2-3 times a week.     b.  Skilled nurse visit note, dated 5/16/25, completed by Staff D, Registered Nurse (RN), identified a wound to patient's midline inner buttocks, with an onset date of 5/16/25.  Wound cleansed per plan of care.    c. Skilled nurse visit note, dated 5/27/25, completed by Staff K, RN, identified wound was cleansed with soap and water, covered with Calmoseptine (moisture barrier cream) and left open to air.  d. IDG meeting note, dated 5/28/25, lacked documentation of an interim physician for wound care to midline inner buttocks.    The hospice provided wound care without an interim physician order and failed to update the plan of care to included needed wound care orders.    6. Patient #14 had a hospice admission date of 10/11/24, a death date of 10/16/24 and received hospice services while residing in a private home.   Clinical record review revealed:   a. The POC, dated 10/11/24 to 1/8/25, identified the patient had a diagnosis of Neurocognitive disorder with lewy bodies and included physician orders for skilled nursing services 1-2 times a day.   b.  Skilled nurse, provided three separate visits on 10/11/25; exceeding the ordered visit frequency of 1-2 visits a day by one visits.    c. The IDG meeting notes, dated 10/16/24, lacked documentation of variations to skilled nursing services ordered 1-2 times a day.     The hospice failed to follow all orders as directed by the IDG.    The above findings were reviewed with the Administrator and Clinical Manager.    Findings include:  Review of the hospice policy, titled Hospice Plan of Care, dated 4/30/25, identified the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including interventions to manage pain and symptoms; a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs; measurable outcomes anticipated from goals, and implementing and coordinating the plan of care; and drugs and treatment necessary to meet the needs of the patient.  Changes in the plan of care will be communicated to the patient/family as they occur with communication being documented in the medical record.  Review of the hospice policy, titled Wound Measurement and Documentation – Hospice, dated 5/29/24, identified wound care is only provided per order from Medical Director, primary care provider, or Wound clinic provider.  1.Patient #1 had a hospice admission date of 5/9/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following:   a. Plan of Care (POC), dated 5/14/21 to 7/21/21, included physician orders for volunteer services 1-2 times per month.    b. Interdisciplinary Group (IDG) meeting note, dated 5/14/25, included documentation volunteer services were ordered on initial plan of care and for the next two weeks with a frequency of 1-2 times per month.  c. IDG meeting note, dated 5/28/25, included documentation volunteer services were ordered at last IDG and for next two weeks with a frequency of 1-2 times per month.  Clinical record lacked documentation of volunteer visits for the month of May or a reason why the services were not performed as ordered.  The hospice failed to provide volunteer visits as ordered per the plan of care.  2. Patient #8 had a hospice admission date of 6/2/25 and received services while residing in an assisted living facility.  Clinical record review revealed the following:  a. Plan of Care, dated 6/2/25 to 8/30/25, included physician orders for skilled nursing services 3 times a week for 1 week then 2 times a week.  b. Skilled nurse visit note, dated 6/6/25, identified a right lower arm skin tear, with an onset date of 6/6/25.  Wound cleansed with soap and water and band-aid applied.  c. IDG meeting note, dated 6/11/25, lacked documentation of an interim physician order for wound care to the right lower arm skin tear.  The hospice provided wound care without an interim physician order and failed to update the plan of care to include needed wound care orders.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the hospice Interdisciplinary Group (IDG) developed patient plans of care that specified scope and frequency for all services required by and provided to patients for 2 of 2 sampled patients (Patient #9 and #14) who received respite services.    Failure to identify scope and frequency for all ordered services increased the potential for hospice services to not adequately meet the needs of hospice patients and families.    Findings include: --- 2.  Patient #9 had a hospice admission date of 5/2/25, received hospice services while residing in a private home from 5/2/25 to 5/18/25 and 5/21/25 to 6/11/25 and residing at the hospital in respite care from 5/19/25 to 5/20/25.  Clinical record review revealed the following:  a. Plan of Care, dated 5/2/25 to 7/30/25, included physician orders to admit patient to hospice services with skilled nursing, hospice aide and social work services.  b. Interdisciplinary Group (IDG) meeting note, dated 5/28/25, included documentation the social worker assisted the patient with respite services.  c. Patient admission setting documentation, dated 5/2/25, identified the patient received routine home care services at home; dated 5/19/25, identified the patient received inpatient respite services at the hospital; and dated 5/21/25, identified the patient received routine home care services at home.  Administrator emailed to surveyor on 6/18/25, Regional Health Services Hospice Protocol Orders, dated 5/19/25, identified admit to hospice respite level of care.  The hospice clinical record failed to identify interim physician orders to change level of care from routine to respite and respite to routine.  The surveyor reviewed the above findings with the Administrator and Clinical Manager.   According to the agency policy titled Hospice Plan of Care, dated 4/30/25, all hospice care and services furnished to patients and their families must follow and individualized written plan of care established by the hospice IDG in collaboration with the attending physician, the patient or representative and the primary caregiver in accordance with the patient's needs.  The hospice IDG will review, revise and document the individual POC as frequently as the patient condition requires.    During an interview on 6/17/25 at 11:06 AM, the Clinical Manager reported there should be an order in the Electronic Medical Record (EMR) identifying when a patient is admitted for respite care.    1.Patient #14 had a hospice admission date of 10/11/24, a death date of 10/16/24, received hospice services while residing in a private residence from 10/11/24 to 10/12/24 and received hospice services while residing at the hospital in respite care from 10/12/24 to 10/16/24.   Clinical record review revealed:   a. The Plan of Care, dated 10/11/24 to 1/8/25, included physician orders to admit patient to hospice services with skilled nursing, hospice aide, social worker, healing touch and music therapy services.    b. IDG meeting note, dated 10/16/24, included documentation aide services were increased while patient was on respite services.    c. Patient admission setting documentation, dated 10/11/24, identified the patient received routine home care services at home; dated 10/11/24; identified the patient received inpatient respite services at the hospital; dated 10/12/24; and identified the patient expired at the hospital on 10/16/24.    Administrator emailed to surveyor on 6/18/25, Regional Health Services Hospice Protocol Orders, dated 10/12/24, identified admit to hospice respite level of care.    The hospice clinical record failed to identify interim physician orders to change level of care from routine to respite.

Based on review of written hospice agreements for services under arrangements, the hospice failed to ensure the written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 3 of 3 sampled services (Medical equipment/supply provider, Pharmacy provider and Massage therapy provider).    Failure to include this provision within the contractual agreement increased the potential that hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care.    Findings include: --- 1.Review of the contract between the hospice and sampled pharmacy provider, dated 9/30/14, identified the contract lacked the following required components:   a. The hospice retains administrative and financial management,   b. The hospice retains oversight of staff and services,   c. All services are delivered in a safe and effective manner by qualified staff and   d. All services are approved by hospice and delivered in accordance with the patient's plan of care.    2.Review of the contract between the hospice and sampled medical equipment/supply provider, dated 5/26/20, identified the contract lacked the following required components:   a. The hospice retains administrative and financial management,   b. The hospice retains oversight of staff and services and  c. All services are approved by hospice and delivered in accordance with the patient's plan of care.    3.Review of the contract between the hospice and sampled massage therapy provider, dated 6/3/25, identified the contract lacked the following required components:   a. The hospice retains administrative and financial management and   b. The hospice retains oversight of staff and services.  The hospice failed to ensure contractual agreements contained all required components for safe and effective patient care.    The above findings were reviewed with the Administrator and Clinical Manager.

Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to ensure clinical records contained pertinent, up-to-date and complete information in a timely manner for 6 of 14 sampled patients with ancillary services (Patients #2, #3, #6, #10, #13, #14).  Failure to maintain accurate clinical records with current patient information increased the risk that hospice staff provided services without up to date information related to the patient's condition, and decreased the ability of hospice staff to communicate effectively in order to coordinate patient care.    Findings include: --- 4. Patient #6 had a hospice start of care date of 3/31/25 and received services while residing in a nursing home.  Clinical record review revealed the following:  a. Plan of Care, dated 3/31/25 to 5/29/25, included physician orders for Healing Touch services 1-2 times per month.  b. Healing Touch paper visit note, dated 5/7/25, identified the note was scanned into the electronic medical record on 6/12/25, 36 days after the visit date, and 22 days late per hospice policy.  c. Healing Touch paper visit note, dated 5/22/25, identified the note was scanned into the electronic medical record on 6/12/25, 21 days after the visit date, and 7 days late per hospice policy.  The hospice failed to have all completed documentation for ancillary disciplines placed in the chart within the required time frame.  5. Patient #13 had a hospice admission date of 11/14/24, a death date of 11/29/24 and received services while residing in a private home.  Clinical record review revealed the following:  a. Plan of Care, dated 11/14/24 to 2/11/25, included physician orders for skilled nurse,  Social work and Healing Touch services.  b. Social Worker bereavement plan of care, dated 11/29/24, identified bereavement mailings would be sent at the following intervals: 2 weeks, 1, 3, 6, 9, 11 and 12 months.  c. Bereavement communication note, dated 12/23/24, identified Social Worker sent bereaved a handwritten note and a thumbprint pendant.  On 6/17/25, Staff H, Social Worker, emailed the following documents to the surveyor:  i. Interdisciplinary Group (IDG) bereavement addendum minutes, dated February 2025, identified Patient #13 quarterly review 3 month, mailings continue to family members and no other needs identified.  ii. IDG bereavement addendum minutes, dated May 2025, identified Patient #13 quarterly review 6 month, mailings continue to family members and no other needs identified.  The hospice failed to document a mailing for the 2 week time frame or a reason why mailing was not sent as identified in bereavement plan of care.  The hospice failed to include bereavement mailing information in the hospice clinical record as required by regulation.  The surveyor reviewed the above findings with the Administrator and Clinical Manager.   According to the hospice policy titled Clinical Record Documentation and Retention, dated 4/30/2025, routine visit notes for nursing, social workers and home care aides are to be completed within two business days of the date of the visit.  All of disciplines are to have completed documentation placed in the chart within two weeks of the date of the visit.    During an interview on 6/17/25 at 11:06 AM, the Clinical Manager identified disciplines completing paper documentation are expected to turn completed notes into the office per agency policy (within two weeks) and agency staff scan the notes into the electronic medical record (EMR).  1.Patient #2 had a hospice admission date of 2/24/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plan of Care (POC), dated 4/25/25 to 6/23/25, identified the patient had a diagnosis of Metachromatic leukodystrophy and included orders for Healing Touch services 1-2 times per month.  b. The healing touch paper visit note, dated 5/18/25, identified the note was scanned into the EMR on 6/12/25, 25 days after the visit and 11 days late (per agency policy).    The hospice failed to have all completed documentation for ancillary services placed in the EMR within the required timeframe.  2. Patient #3 had a hospice admission date of 1/31/23 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 3/21/25 to 5/19/25, identified the patient had a diagnosis of Heart failure and included orders for Healing Touch services 1-2 times a month.    b. The healing touch paper visit note, dated 5/19/25, identified the note was scanned into the EMR on 6/12/25, 24 days after the visit and 10 days late (per agency policy).    The hospice failed to have all completed documentation for ancillary services placed in the EMR within the required timeframe.    3. Patient #10 had a hospice admission date of 5/12/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 5/12/25 to 8/9/25, identified the patient had a diagnosis of Alzheimer's disease and included orders for Healing Touch services 1-2 times a month.  b. The healing touch paper visit note, dated 5/22/25, identified the note was scanned into the EMR on 6/12/25, 21 days after the visit and 7 days late (per agency policy).    c. The healing touch paper visit note, dated 5/28/25, identified the note was scanned into the EMR on 6/12/25, 15 days after the visit and 1 day late (per agency policy).   The hospice failed to have all completed documentation for ancillary services placed in the EMR within the required timeframe.

Based on review of the written agreements between the hospice and nursing facilities providing respite care, the hospice failed to ensure the written agreements identified the nursing facilities would send a copy of the hospice patient's discharge summary to the hospice at the time of discharge from the facility for 2 of 2 sampled written agreements (Nursing home A and Nursing home B).    Failure to ensure the nursing facilities provided the hospice with a discharge summary upon nursing facility discharge of a hospice patient decreased the possibility of continuity of care when the patient returned home.    Findings include: --- 1.The hospice had a contractual agreement with Nursing facility A, dated 1/1/25.  The contractual agreement failed to specify the nursing facility would provide the hospice agency with a copy of the discharge summary at the time of discharge and failed to specify a copy of the patient's facility clinical record is available to the hospice at the time of discharge.     2. The hospice had a contractual agreement with Nursing facility B, dated 11/10/22.  The contractual agreement failed to specify the nursing facility would provide the agency hospice with a copy of the discharge summary at the time of discharge and failed to specify a copy of the patient's facility clinical record is available to the hospice at the time of discharge.    The above findings were reviewed with the Administrator and Clinical Manager.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks.  The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor.  Based on review of employee personnel files, the hospice failed to ensure completion of a criminal background check for 1 of 6 sampled employees who began serving hospice patients since their last survey, dated 6/9/22.  The hospice reported hiring 22 employees since the last survey.    Failure to complete criminal background checks as required by Federal regulation, increased the potential risk of harm to agency patients from hospice volunteers and/or employees who had direct patient contact. --- Findings include:  Staff G, volunteer, had a start date of December 2024.  Staff G's personnel file included documentation of a completed criminal history background check, dated 6/17/25, approximately 6 months after Staff G’s start date.   Hospice staff failed to complete a criminal history background check on all staff prior to hiring.  The above findings were reviewed with the Administrator and Clinical Manager.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks.  The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor.  Based on review of employee personnel files, the hospice failed to ensure completion of a dependent adult abuse or child abuse record checks for 1 of 6 sampled employees who began serving hospice patients since their last survey, dated 6/9/22.  The hospice reported hiring 22 employees since the last survey.   Failure to complete dependent adult and child abuse record checks as required by State regulation, increased the potential risk of harm to agency patients from employees who had direct patient contact. --- Findings include:  Staff G, volunteer, had a start date of December 2024.  Staff G's personnel file included documentation of completed criminal history, dependent adult and child abuse record checks, dated 6/17/25, approximately 6 months after Staff G's start date.   Hospice staff failed to complete dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring.  The above findings were reviewed with the Administrator and Clinical Manager.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the provision of care in accordance with the patient's plan of care for 3 of 5 sampled patients with wound care/dressing changes (Patients #4, #9 and #10). Failure to follow the patient's Plan of Care as directed by the Interdisciplinary Team puts the patient at risk of inconsistent care that may not meet the needs of the patient. Findings include: According to the hospice policy, titled Hospice Plan of Care, dated 1/19/22, the all hospice care and services furnished to patients and their families must follow an individualized written Plan of Care (POC) established by the hospice interdisciplinary team (IDT) in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver, and in accordance with the patient's needs. The POC must include all drugs and treatments necessary to meet the needs of the patient. The hospice POC for a resident of a nursing facility will be established and maintained in consultation with the facility representatives. 1. Patient #4 had a hospice admission date of 5/3/22 and received hospice services while residing in a nursing home. The POC dated 5/3/22 to 7/31/22, included orders for skilled nursing and hospice aide services. Clinical record review revealed the following: a. A skilled nursing visit note, dated 5/19/22, documented an initial assessment of a wound to the patient's right inner buttocks and the wound was cleansed with soap and water and duoderm was applied by nursing facility staff. The patient's reddened area to buttocks had opened up and facility staff covered it with duoderm per their usual orders. b. A skilled nursing visit, dated 5/20/22, documented right inner buttocks wound care was performed by nursing facility staff and a duoderm was applied. c. A skilled nursing visit, dated 5/20/22, documented right inner buttocks wound care was performed by nursing facility staff and a duoderm was applied. d. A skilled nursing visit, dated 5/26/22, documented right inner buttocks wound was healed. e. The clinical record lacked documentation of a physician order for wound care orders for the right inner buttock, including application of a duoderm dressing. The nurse failed to follow the POC. 2. Patient #9 had a hospice admission date of 1/18/22, received hospice services while residing in a nursing home and died in the nursing home on 5/25/22. The POC dated 3/26/22 to 4/21/22, included orders for skilled nursing, hospice aide, social work, spiritual care, massage therapy and music therapy services. Clinical record review revealed the following: a. A skilled nursing visit note, dated 4/5/22, documented the patient complained of sacral discomfort and the nurse applied a meplix border dressing to help ease the discomfort. The clinical record lacked documentation of a physician order for application of a meplix border dressing to the sacrum. On 6/8/22 at 11:50 AM, the Clinical Manager confirmed no order for the meplix border dressing was obtained prior to application. The nurse failed to follow the POC. 3. Patient #10 had a hospice admission date of 5/3/22 and received hospice services while residing in a nursing home. The POC dated 5/3/22 to 7/31/22, included orders for skilled nursing and hospice aide services. Clinical record review revealed a skilled nursing visit note, dated 5/20/22, documented the nurse noted a dressing on the patient's left elbow. The nursed noted a skin tear of the left elbow and cleansed the skin tear with wound cleanser and dressed the wound with Vaseline gauze and Keri gauze to secure in place. The clinical record lacked documentation of a physician order for wound care orders for the left elbow skin care, including application of Vaseline and Keri gauze. The nurse failed to follow the POC. The above findings were reviewed with the Hospice Administrator and Clinical Manager. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, and staff interview, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 2 of 11 sampled patients (Patients #5 and #6). Failure of the hospice Interdisciplinary Group (IDG) members maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: Review of the hospice's policy, titled Interdisciplinary Team (IDT), dated 1/19/2022, identified the interdisciplinary team is designated to provide coordination of care and ensure continuous assessment of each patient's and family's needs and implementation of the interdisciplinary plan of care. Interview on 3/8/22 at 10:14 AM with Hospice Administrator/Clinical Manager reported any missed visits should be discussed and documented in the IDG notes. 1. Patient #6 had a hospice admission date of 12/2/21 and received hospice services while residing in a private home residence. Clinical record revealed: a. The Plan of Care, dated 3/2/22 to 5/20/22, included IDG orders for hospice social work services 1 to 2 times per month. b. The clinical record lacked documentation of a social work visit was completed the month of May. c. The IDG update to the POC, dated 5/4/2022, failed to include documentation which identified the IDG was aware of the missed social work visit the month of May. Interview on 6/9/2022 at 10:37 AM with the hospice Clinical Manager confirmed no social work visit occurred the month of May. 2. Patient #5 had a hospice admission date of 4/12/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Plan of Care, dated 4/12/22 to 7/10/22, included orders for music enrichment services 1-2 times per month. b. Music enrichment visit notes, dated 4/13/22, 4/18/22 and 4/27/22, included documentation services were provided. c. The IDG meeting note, dated 5/4/22, lacked documentation of the extra music enrichment visit for the month of April. The clinical record failed to include a physician order for the extra music enrichment visit. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the registered nurses developed individualized patient specific written instructions directing the care provided by each hospice aide for 3 of 9 sampled patients receiving hospice aide services. (Patients #4, #6 and #10). The hospice reported a total of 20 patients received hospice aide services at the time of the survey. Failure to provide patient specific, written instructions for hospice aides, directing them which tasks to perform and how frequently, for each patient; increased the risk hospice patients did not receive the services as ordered by the patient's physician and by the Interdisciplinary Team (IDT) Care Plan, to meet each patient's needs. Findings include: According to the hospice policy, titled Hospice Aide Services, dated 10/27/20, the hospice aide receives patient care assignments from a Registered Nurse who instructs the aide utilizing the plan. 1. Patient #4 had a hospice admission date of 5/3/2022 and received services while residing in a nursing home residence. Clinical record review revealed: a. The Plan Of Care, dated 5/3/22 to 7/31/22, included IDG orders for skilled nursing and hospice aide services and instructed the aide to assist patient to the bathroom if the patient is needing the bathroom, provide foot care, may apply lotion to the legs, feet, arms, back, and/or trunk per patient request, and perform pericares if patient is incontinent of urine and/or stool. b. The Hospice Aide Care Plan, for the certification periods, 5/3/22 to 7/31/22, instructed the aide to assist patient to the bathroom if the patient is needing the bathroom, provide foot care, may apply lotion to the legs, feet, arms, back, and/or trunk per patient request, and perform pericares if patient is incontinent of urine and/or stool. c. The initial comprehensive assessment, completed at start of care and dated 5/3/22, documented the patient's use of a gait belt. Interview on 6/8/22 at 12:20 PM with Staff F, Hospice Aide, reported, he/she used a gait belt when providing patient assistance to the bathroom. Interview on 6/8/22 at 12:20 PM with Staff G, Hospice Aide, reported he/she used a gait belt when providing patient assistance to the bathroom. The aide assignment lacked specific instructions including the use of the gait belt to safely assist the patient to the bathroom. d. The home care aide assigned the task of foot care for the aide to complete. Interview with Staff F, Hospice Aide, reported foot care is applying lotion to the patient's feet. Interview with Staff G, Hospice Aide, reported foot care is applying lotion to the feet or soaking of the feet. The aide assignment was not specific to the patient as to define what foot care was to be performed. 2. Patient #6 had a hospice admission date of 12/2/21 and received services while residing in a private home residence. Clinical record review revealed: a. The Plans Of Care, dated 3/2/22 to 5/30/22, and 5/31/22 to 7/29/22, included IDG orders for skilled nursing and hospice aide services and instructed the aide to assist patient with bathing in walk in tub if requested; assist with meal preparation, if present at meal time, may complete incontinent care, if needed, assist patient with dressing if requested, may apply lotion to back, arms, hands, and feet, offer patient a back rub, and massage therapy for comfort. b. The Hospice Aide Care Plan, for the certification periods, 5/3/22 to 7/31/22, instructed the aide to assist patient to the bathroom if the patient is needing the bathroom, provide foot care, may apply lotion to the legs, feet, arms, back, and/or trunk per patient request, and perform pericares if patient is incontinent of urine and/or stool. The use of the words "MAY" and "OFFER" allow the aide to decide if the task needs to be performed to apply the lotion and asking the patient if the patient wants a backrub, rather than assigning the task to the aide. The aide assignment lacked specific instructions for the aide to perform the tasks. 3. Patient #10 had a hospice admission date of 1/18/22, received services while residing in a nursing home and died at the nursing home on 5/25/22. Clinical record review revealed: a. The Plans Of Care, dated 1/18/22 to 4/17/22, 4/18/22 to 7/16/22, included IDG orders for skilled nursing and hospice aide services and instructed the aide to assist with hoyer lift transfers, if needed, apply lotion to feet, assist with meal set up or feeding, if visit is made around lunch time, empty foley catheter and report total output to facility nurse, may provide catheter care, may provide incontinent care, assist patient with dressing, if needed, make sure dentures are in, may apply barrier cream to skin folds and buttocks, may apply barrier cream to skin folds and pressure ulcer on bottom, may assist facility staff with transfers using the EZ stand lift, may assist patient with GranPad, may offer to help patient shave, offer foot rub, and offer the patient to help make a phone call. b. The Hospice Aide Care Plan, for the certification periods, 1/18/22 to 4/17/22, 4/18/22 to 7/16/22, instructed the aide to assist with hoyer lift transfers, if needed, apply lotion to feet, assist with meal set up or feeding, if visit is made around lunch time, empty foley catheter and report total output to facility nurse, may provide catheter care, may provide incontinent care, assist patient with dressing, if needed, make sure dentures are in, may apply barrier cream to skin folds and buttocks, may apply barrier cream to skin folds and pressure ulcer on bottom, may assist facility staff with transfers using the EZ stand lift, may assist patient with GranPad, may offer to help patient shave, offer foot rub, and offer the patient to help make a phone call. The use of the words "MAY" and "OFFER" allow the aide to decide if the task needs to be performed to perform catheter care, incontinent care, applying barrier cream, assisting with hoyer lift, GranPad, shaving, foot rub, and making a phone call. The aide assignment lacked specific instructions for the aide to perform the tasks. The above findings were reviewed with the Hospice Administrator and Clinical Manager. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review and hospice policy review, the hospice failed to ensure hospice aides provided services as ordered by the Interdisciplinary Team according to an individualized plan of care for 6 of 9 sampled patients who received hospice aide services (Patients #2, #3, #4, #6, #10, and #11). The hospice reported a total of 20 patients received hospice aide services at the time of the survey. Failure to provide hospice aide services as ordered on the plan of care increased the risk that hospice patients' personal care needs were not met. Findings include: According to the hospice policy, titled Hospice Aide Services, dated 10/27/2020, the hospice aide receives patient care assignments from a registered nurse who instructs the aide on utilizing a care plan. 1. Patient #10 had a hospice admission date of 1/18/22, received hospice services while residing in a nursing home and died at home on 1/18/22. Clinical record review revealed: a. The Plan of Cares (POC), dated 1/18/22 to 4/17/22 and 4/18/22 to 7/16/22, included Interdisciplinary Group (IDG) orders for skilled nursing and aide services. b. The aide care plan included RN (registered nurse) instructions to the aide to complete the tasks apply lotion to feet, empty foley catheter, report total output to facility nurse, may provide catheter care, and may apply barrier cream to skin folds and buttocks, and may offer to shave patient. c. Hospice aide visit notes, dated 3/28/22, 3/30/22, 3/31/22, 4/6/22, 4/11/22, 4/18/22, 4/20/22, 4/21/22, 4/25/22, 4/27/22, and 5/23/22, documented empty foley catheter was not performed due to being "not applicable this visit". The notes lacked documentation of why the task was not performed. d. Hospice aide visit note, dated 3/28/22 and 3/30/22,apply barrier cream to skin folds/buttocks was not performed due to being "not applicable this visit". The notes lacked documentation of why the task was not performed. e. Hospice aide visit note, dated 3/30/22 and 3/31/22, documented task lotion to feet was not performed due to being "not applicable this visit". The notes lacked documentation of why the task was not performed. f. Hospice aide visit note, dated 3/31/22, 4/7/22, 4/8/22, 4/18/22, 4/20/22, documented task shave patient was not performed due to being "not applicable this visit". The notes lacked documentation of why the task was not performed. The aide did not complete tasks as assigned. 2. Patient #6 had a hospice admission date of 12/2/21 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The Plan of Cares (POC), dated 3/2/22 to 5/30/22 and 5/31/22 to 7/29/22, included Interdisciplinary Group (IDG) orders for skilled nursing and aide services. b. The aide care plan included RN (registered nurse) instructions to the aide to complete the tasks may apply lotion to back, arms, hands and feet, offer back rub to patient, and massage therapy for comfort. c. Hospice aide visit notes, dated 4/8/22, 4/11/22, 4/15/22, 4/18/22, 4/22/22, 4/25/22, 5/2/22, 5/6/22, 5/9/22, 5/13/22, 5/16/22, 5/20/22, 5/23/22, 5/27/22, 5/31/22, and 6/3/22, documented applying lotion was not performed due to being "not applicable this visit". The notes lacked documentation of why the task was not performed. d. Hospice aide visit note, dated 4/8/22, 4/11/22, 4/15/22, 4/18/22, 4/22/22, 4/25/22, 5/2/22, 5/6/22, 5/9/22, 5/13/22, 5/16/22, 5/20/22, 5/23/22, 5/27/22, 5/31/22, and 6/3/22, documented offer back rub was not performed due to being "not applicable this visit". The notes lacked documentation of why the task was not performed. e. Hospice aide visit note, dated 4/8/22, 4/11/22, 4/15/22, 4/18/22,4/22/22, 4/25/22, 5/2/22 and 5/13/22, massage therapy was not performed due to being "not applicable this visit". The notes lacked documentation of why the task was not performed. Interview on 6/8/22 at 12:20 PM with Staff G, Hospice Aide reported the massage therapy is completed by massage therapist and that is why the aide documented "not applicable this visit". The aide would massage the patient's neck/back at times and that was when "done" was documented. The aide did not complete tasks as assigned. 3. Patient #2 had a hospice admission date of 4/5/22 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The Plan of Care (POC), dated 4/5/22 to 7/3/22, included Interdisciplinary Group (IDG) orders for skilled nursing and aide services. b. The aide care plan included RN (registered nurse) instructions to the aide to complete the tasks of assist patient with a bed bath if unable to shower, shower, and shampoo. c. Hospice aide visit note, dated 4/14/22, documented shampoo was not performed due to being "not applicable this visit". The notes lacked documentation of why the task was not performed. The aide did not complete tasks as assigned. 4. Patient #4 had a hospice admission date of 5/3/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 5/3/22 to 7/31/22, included Interdisciplinary Group (IDG) orders for skilled nursing and aide services. b. The aide care plan included RN (registered nurse) instructions to the aide to complete the tasks of assisting the patient to the bathroom if the patient is needing assistance to use the bathroom, provide foot care, may apply lotion to legs, feet, arms, back and/or trunk per patient request, and perform pericares if patient is incontinent of urine and/or stool. c. Hospice aide visit notes, dated 5/10/22, 5/17/22, 5/26/22, 5/31/22 and 6/2/22 documented foot care was not performed due to being "not applicable this visit". The notes lacked documentation of why the task was not performed. The aide did not complete tasks as assigned. d. Hospice aide visit note, dated 5/10/22, 5/17/22, documented in the narrative note the aide performed a partial sponge bath. The aide performed a task that was not assigned by the nurse. 5. Patient #11 had a hospice admission date of 4/5/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 4/5/22 to 7/3/22, included orders for hospice aide services 2 times per week. b. The hospice aide care plan, dated 4/7/22, included tasks diet - encourage eating if present at mealtime, elimination - incontinent care if brief is soiled, hygiene - shave - electric offer to assist with shaving, hygiene - skin care - offer to apply lotion, and vital signs - report patient pain to facility nurse and hospice nurse. c. The hospice aide visit notes, dated 4/26/22 and 5/24/22 included documentation all tasks were not applicable but lacked a reason why tasks were not completed. d. The IDG meeting notes, dated 5/4/22 and 6/1/22, lacked documentation of missed hospice aide visits. 6. Patient #3 had a hospice admission date of 1/3/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 4/3/22 to 7/1/22, included orders for hospice aide services 2 times per week. b. The hospice aide care plan, dated 1/16/22, included tasks activity - recognize and report any changes in the patient's skin condition, assist with transferring/ambulating patient the toilet as needed, offer to play music on patient's virtual assistant technology prior to leaving visit, offer to rub patient's feet, and provide companionship and socialization. c. The hospice aide visit note, dated 5/18/22, lacked documentation of any tasks, completed or not completed. d. The IDG meeting notes, dated 5/18/22 and 6/1/22, lacked documentation of a missed hospice aide visit. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure all documentation in the clinical record included an appropriate date and signature for 9 of 9 sampled patients with massage and music therapy services(Patients #2, #3, #5, #6, #7, #8, #9, #10, and #11). Failure to ensure all clinical record documentation, and each patient's clinical record was complete, timely and appropriately authenticated, decreased the ability of hospice staff to communicate and coordinate patient care effectively, and to provide safe, effective hospice services to its patients. Findings include: According to the hospice policy, titled Clinical Record Documentation and Retention, dated 8/23/21, all care will be recorded on appropriate form, signed , dated and timed. 1. Patient #10 had an admission to hospice on 1/18/22, received services while residing in a nursing home and died at the nursing home on 5/25/22. Clinical record review revealed the following: a. Music therapy visit notes, dated 3/30/22, 4/5/22, 4/19/22, 5/3/22, and 5/17/22, included the author's signature and date, however, failed to include the massage therapist's title. b. Massage therapy visit note, dated 4/8/22, included the author's signature and date, however, failed to include the massage therapist's title. 2. Patient #2 had an admission to hospice on 4/5/22 and received services while residing in a private residence. Clinical record review revealed a massage therapy visit note, dated 4/28/22, included the author's signature and date, however, failed to include the massage therapist's title. 3. Patient #6 had an admission to hospice on 12/2/21 and received services while residing in a private residence. Clinical record review revealed massage therapy visit notes, dated 4/11/22, 4/18/22, 4/25/22, 5/2/22, 5/9/22, 5/16/22, 5/23/22, and 5/30/22, included the author's signature and date, however, failed to include the massage therapist's title. 4. Patient #9 had an admission to hospice on 3/26/22 and received services while residing in a private residence. Clinical record review revealed massage therapy visit notes, dated 4/6/22 and 4/20/22, included the author's signature and date, however, failed to include the massage therapist's title. 5. Patient #3 had a start of care date of 1/3/22 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 4/3/22 to 7/1/22, included orders for massage therapy, music enrichment and social worker services. b. Massage therapy paper visit notes, dated 4/18/22, 5/2/22 and 5/16/22, included a handwritten signature and date but lacked a title. c. Music enrichment paper visit notes, dated 4/13/22, 4/25/22, 5/10/22 and 5/24/22, included a handwritten signature and date but lacked a title. d. Social worker electronic visit note, dated 5/20/22, was electronically signed as completed on 5/25/22, 3 business days after the visit, 1 day late per agency policy. 6. Patient #5 had a start of care date of 4/12/22 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 4/12/22 to 7/10/22, included orders for massage therapy and music enrichment services. b. Massage therapy paper visit notes, dated 4/29/22, 5/13/22 and 5/27/22, included a handwritten signature and date but lacked a title. c. Music enrichment paper visit notes, dated 4/13/22, 4/18/22, 4/27/22, 5/11/22 and 5/18/22, included a handwritten signature and date but lacked a title. 7. Patient #8 had a start of care date of 7/9/2020, a discharge date of 2/23/22 and received services while residing in a private home. Clinical record review revealed: a. The Plan of Care, dated 12/31/21 to 2/28/22, included orders for massage therapy and music enrichment services. b. Massage therapy paper visit notes, dated 12/27/21, 1/3/22, 1/10/22, 1/17/22, 1/31/22, 2/7/22, 2/14/22 and 2/21/22, included a handwritten signature and date but lacked a title. c. Music enrichment paper visit notes, dated 12/29/21, 1/7/22, 1/12/22, 1/19/22, 1/25/22, 2/2/22, 2/16/22 and 2/23/22, included a handwritten signature and date but lacked a title. 8. Patient #11 had a start of care date of 4/5/22, a discharge date of 5/26/22 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 4/5/22 to 7/3/22, included orders for massage therapy and music enrichment services. b. Massage therapy paper visit note, dated 5/13/22, included a handwritten signature and date but lacked a title. c. Music enrichment paper visit notes, dated 4/19/22, 5/3/22 and 5/17/22, included a handwritten signature and date but lacked a title. 9. Patient #7 had a start of care date of 5/31/22, a death date of 6/7/22 and received services while residing in a private home. Clinical record review revealed: a. The Plan of Care, dated 5/31/22 to 8/28/22, included orders for social worker services. b. Social worker electronic visit note, dated 5/31/22, was electronically signed as completed on 6/6/22, 4 business days after the visit, 2 days late per agency policy. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, nursing home medication and treatment administration records, hospice policy review, nursing home staff interview and hospice staff interview, the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the nursing home for 2 of 2 sampled patients (Patients #3 and #4) with an on-site visit to the patient's nursing home residence. The hospice reported a total of 14 patients received routine hospice services while residing in a nursing home. Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for not receiving care and/or treatment according to the hospice philosophy. Findings Include: According to the hospice policy, titled Hospice Plan of Care, dated 1/19/2022, the hospice Plan of Care for a resident of a nursing facility will be established and maintained in consultation with the facility representative. 1. Patient #4 had a hospice admission date of 5/3/22 and received hospice services while residing in a nursing home. The Plan of Care (POC), dated 5/3/22 to 7/31/22, included IDT orders for skilled nursing services. On 6/7/22 at 11:24 AM, during an on-site visit to the patient's nursing home, the Administrator provided a copy of the patient's medication and treatment administration records for October and November 2018. Review of the nursing home's current medication administration record (MAR) and treatment administration record (TAR) compared to the hospice's medication status sheet, dated 6/7/22, identified the following medication and treatment discrepancies: a. The nursing home's MAR and TAR included an order for Lorazepam 0.5 milligrams (mg) three times per day. The hospice's medication status sheet and clinical record lacked documentation of a physician order for the medication. b. The nursing home's MAR and TAR included an order for Tylenol 325 mg 2 tablets every 4 hours as needed for pain. The hospice's medication status sheet and clinical record lacked documentation of a physician order for the medication. c. The nursing home's MAR and TAR included an order for Calmoseptine to buttocks and coccyx area twice per day and as needed two times a day for urinary incontinence. The hospice's medication status sheet and clinical record lacked documentation of a physician order for the medication. The hospice RN case manager failed to coordinate medications and treatment with the hospice. The surveyor provided the hospice Clinical Manager with findings and the Clinical Manager agreed the medication discrepancies occurred. 2. Patient #3 had a hospice admission date of 1/3/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The hospice Plan of Care, dated 4/3/22 to 7/1/22, and medication profile, printed 6/6/22, included medication order for miralax 17 grams orally once a day as needed for constipation. b. The nursing home Medication Administration Record included orders for miralax 17 grams in the morning, with a start date of 3/22/22 and miralax 17 grams once a day as needed for constipation. The hospice clinical record lacked documentation of the scheduled miralax order. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.